The nursing home failed to provide proper pressure ulcer care and failed to prevent new pressure sores from developing. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 686 — 42 CFR §483.25(b) — S/S: G
Nursing home report
THE PEARL OF DOWNERS GROVE
DOWNERS GROVE, IL · Medicare-certified · 145 beds
Needs attention
For-profitChain member
1 of 5 overall
1 of 5 stars overall. The Pearl of Downers Grove has 1-star staffing and quality ratings, 2-star health inspection, nurse staffing below the federal benchmark (3.61 vs 4.1 hours per resident per day), $30,794 in fines in the last 24 months, and a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.6123 hrs/resident/day
Quality measures
Last inspection: January 23, 2026Penalties, last 24 months: $30,794recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.6123.
Staffing detail
- Registered nurses
- 0.77
- Licensed practical nurses
- 0.76
- Nurse aides
- 2.08
- Weekend nursing
- 3.40
Hours per resident per day.
Total staff turnover: 78%
Registered nurse turnover: 69%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
31.4%Steady
Residents with a fall causing major injury
2.4%Improving
Residents with pressure ulcers (bedsores)
7.1%Worsening
Residents with a urinary tract infection
0%Steady
Residents who lost too much weight
3%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
21.7%Improving
Residents whose ability to walk got worse
33.3%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
6%Worsening
Short-stay residents newly given an antipsychotic
2.9%Improving
Residents with a long-term catheter
0.9%Improving
Residents with new or worsening incontinence
31.2%Improving
Residents with depressive symptoms
61.7%Worsening
Long-stay residents given the seasonal flu vaccine
97.4%Steady
Long-stay residents given the pneumonia vaccine
86.1%Worsening
Short-stay residents given the seasonal flu vaccine
80.4%Steady
Short-stay residents given the pneumonia vaccine
42.2%Worsening
What the inspectors found
The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited April 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
The home failed to notify the resident and family in time before a transfer or discharge, including their right to appeal. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 623 — 42 CFR §483.15 — S/S: F
The home failed to tell residents or their representatives in writing how long their bed would be held after a hospital transfer or therapeutic leave. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 625 — 42 CFR §483.15 — S/S: F
The home failed to provide enough nursing staff each day and ensure a licensed nurse was in charge on every shift. Cited April 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 725 — 42 CFR §483.35 — S/S: F
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $30,794 was recorded.
- INSPECTION
Health inspection found 19 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $30,794 in total fines.
- $30,794
Federal fine
Apr 14, 2025
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of PEARL HEALTHCARE · 15 homes · 2.5 stars avg
- Occupancy
- 90.2 residents on an average day (62% of 145 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 36 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.